HYPEREMESIS GRAVIDARUM

Nausea and/or vomiting occur normally during pregnancy and can affect up to 90% of pregnancies. Symptoms often start at 5–6 weeks’ gestation and usually subside by 20 weeks. Dietary changes can help alleviate the symptoms. These include eating before or as soon as feeling hungry; additional snacks; small, frequent meals; avoiding triggers; and consuming ginger. Nausea and vomiting that develop after 10 weeks’ gestation may also be caused by conditions unrelated to pregnancy (e.g., gastrointestinal disorders) and should be investigated (Smith et al., 2022a, 2022b).

Nausea and vomiting that occurs regularly beyond 20 weeks’ gestation and involve hypovolemia and weight loss >5% of prepregnancy body weight during pregnancy is termed hyperemesis gravidarum, or severe, persistent nausea and vomiting. The cause of hyperemesis is unknown, however elevated hormonal levels and relaxation of smooth muscle resulting in delayed stomach emptying, along with stress, are believed to play a part in this disorder.

Patients with hyperemesis gravidarum frequently become dehydrated and may have metabolic acidosis as a result of starvation. In addition, patients may become alkalotic from a loss of hydrochloric acid during vomiting. Electrolyte imbalances such as hypokalemia and vitamin deficiencies are also common in patients with hyperemesis gravidarum. Ultimately, long-term nausea and vomiting can cause renal and/or gastrointestinal impairment in the pregnant patient.

Dehydration occurring from hyperemesis gravidarum may also result in preterm labor, which can negatively impact the fetus. In addition, dehydration impairs placental perfusion and affects nutrient intake and oxygenation of the fetus. Moreover, due to the severe nausea and vomiting associated with hyperemesis, poor maternal nutrient intake is common and fetal growth may be compromised, causing low-birth-weight infants.

Signs and Symptoms

Normal first-trimester nausea and vomiting can be challenging for pregnant women. However, patients with hyperemesis gravidarum are frequently debilitated by unrelenting vomiting and dry retching. Common signs and symptoms of hyperemesis gravidarum include:

• Poor appetite
• Poor nutritional intake
• Vomiting beyond 20 weeks’ gestation
• Significant weight loss (>5% of prepregnancy weight)
• Ketonuria unrelated to other causes
• Dehydration (dry mouth and mucous membranes, decreased skin elasticity [turgor], and dark, concentrated urine)

Medical Treatment

When diagnosing hyperemesis gravidarum, it is important to investigate the underlying causes of nausea and vomiting. These causes can include gastroenteritis, pancreatitis, hepatitis, peptic ulcer disease, and pyelonephritis. Patients usually require intravenous fluids and antiemetics to manage hyperemesis. While most care for hyperemesis is provided in the patient’s home, some patients may require hospitalization for nutritional support via enteral or parenteral access.

Nursing Care

Nurse caring for patients with hyperemesis gravidarum includes monitoring and providing physical care as well as psychosocial support. The nurse will administer IV fluids and antiemetics. Intake and output are carefully monitored, as well as gastrointestinal status. Laboratory results (e.g., ketones, electrolytes, complete blood count, liver enzymes) are carefully monitored, with abnormal results reported to the appropriate healthcare practitioner. It is also important to monitor for weight loss since the constant, prolonged nausea and vomiting associated with hyperemesis may easily result in malnutrition for pregnant patients.

Often patients are unable to work or tend to activities of daily living. This underscores the need for the nurse to address the psychosocial needs of patients, which may involve simply listening to the patient or a referral to appropriate resources.

Patient Teaching

Most of the nursing care provided to patients with hyperemesis gravidarum involves teaching the patient strategies to manage the associated nausea and vomiting. It is important for patients to understand the need to eat small, frequent low-fat meals throughout the day. Usually, toast, dry cereal, and other bland foods (e.g., bananas, rice, and apples) are well tolerated. Consistent protein intake is also helpful in preventing nausea (Smith et al., 2022b). Patients are instructed to identify and avoid foods and odors that trigger nausea and vomiting.

In addition, patients should be encouraged to maintain adequate fluid intake to prevent dehydration. Since constant, prolonged vomiting affects the patient’s mouth and desire to eat, nurses also teach and encourage patients to provide and maintain adequate oral care. It is important to provide appropriate instructions regarding their medications to patients who are prescribed antiemetics.

Positive ketones in the urine indicate that patients are using fat stores to provide energy to themselves and their growing fetuses. For patients who are required to use urine dipsticks to monitor ketones while at home, the nurse provides instruction in their appropriate use.

Nurses instruct patients to notify their healthcare practitioner if they notice dark urine, bloody vomitus, abdominal pain, dehydration, lack of urine output for eight hours, positive ketones, or inability to keep food down for 24 hours.